Healthcare Provider Details

I. General information

NPI: 1194615187
Provider Name (Legal Business Name): JAMIE LYNN VACEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/09/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 WASHINGTON AVE
MOUNT PLEASANT WI
53177-1604
US

IV. Provider business mailing address

10180 WASHINGTON AVE
MOUNT PLEASANT WI
53177-1604
US

V. Phone/Fax

Practice location:
  • Phone: 262-687-7577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number890726
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: